Information Collection

Claimant's Statement About Loan Of Food Or Shelter, Statement About Food Or Shelter Provided To Another

IC 115717 under ICR 199404-0960-005 · OMB 0960-0529.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0529 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CLAIMANT'S STATEMENT ABOUT LOAN OF FOOD OR SHELTER, STATEMENT ABOUT FOOD OR SHELTER PROVIDED TO ANOTHER	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-5062				No	No
Form	L5063				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 131,080	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	131,080	35,134	95,946
Annual IC Time Burden (Hours)	29,847	8,000	21,847
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.